Journal name: Adolescent Health, Medicine and Therapeutics Article Designation: Review Year: 2018 Volume: 9 Adolescent Health, Medicine and Therapeutics Dovepress Running head verso: Floros Running head recto: Gambling disorder in adolescents: prevalence, developments, and challenges open access to scientific and medical research DOI: http://dx.doi.org/10.2147/AHMT.S135423 Open Access Full Text Article REVIEW Gambling disorder in adolescents: prevalence, new developments, and treatment challenges Georgios D Floros Abstract: Research on adolescence gambling over the past twenty years has revealed significant incidence and prevalence rates and highlighted the possible negative effects on an adolescent’s 2nd Department of Psychiatry, Medical School, Aristotle University of well-being. Several risk and protective factors have also been identified. Over the course of the Thessaloniki, Thessaloniki, Greece past few years, technological advances have heralded the advent of new avenues for gambling as well as new opportunities to gamble without any direct monetary exchange. This review article examines those established trends as well as the new issues that we are faced with, in order to accurately portray the current challenges in research, prevention, and treatment. Keywords: adolescence, gambling disorder Introduction Adolescent gambling has come into focus since the seminal paper of Lesieur and Klein1 reported high percentages of both incidence and prevalence rates, for some form of gambling, among New Jersey high-school students. After a multitude of prevalence studies in the space of twelve years, the National Research Council concluded, in 1999, that the proportion of pathological gambling among adolescents in the US could be more than three times that of adults.2 Compared to the timeframe of those early research findings, gambling practices and opportunities have evolved to the point where they are widely available and viewed as a socially acceptable form of entertainment, while becoming increasingly attractive to young people (e.g., social casino gambling,3 online gambling,4 mobile gambling,5 gambling within online video games,6 simulated gambling within other forms of entertainment7). This leads to unique challenges in defining what constitutes gambling, ascertaining its prevalence and providing effec- tive treatment options. The fact that it remains a prohibited activity complicates and attenuates measurement issues, yet its reported worldwide prevalence indicates that it remains a serious mental health challenge. Classification and research As with adult gambling behavior, we can perceive adolescent gambling behavior Correspondence: Georgios D Floros forming a continuum that ranges from non-gambling to occasional/recreational/non- 2nd Department of Psychiatry, Aristotle problematic/social gambling to at-risk gambling to problem/pathological/compulsive University of Thessaloniki, 196 Langada Street, Thessaloniki 564 29, Greece or disordered gambling, as is the current term on the fifth edition of the Diagnostic Tel +30 694 432 4565 and Statistical Manual of Mental Disorders (DSM-5).8 Similar to adults, these exces- Fax +30 231 220 3122 Email [email protected] sive forms of gambling typically result in severe psychosocial, behavioral, economic, submit your manuscript | www.dovepress.com Adolescent Health, Medicine and Therapeutics 2018:9 43–51 43 Dovepress © 2018 Floros. This work is published and licensed by Dove Medical Press Limited. 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Relevant studies containing prevalence data are pre- literature accepts that between 4% and 8 % of adolescent sented in Table 1. gamblers are experiencing significant gambling-related The large variance among those results highlights the problems.9 Those include various psychosocial issues, poor difficulties in accurately measuring the phenomenon. The academic performance, intrafamilial conflict, economic hard- validity of the results is hard to ascertain since it depends ship, difficult peer relationships and social exclusion, diffuse to a large extent on the willingness of the subject to answer and multiple mental health issues including increased rates candidly, given that the issue is a sensitive one; this in turn of suicide ideation and attempts, drug and alcohol use, and is relative to the recruitment method and incentive to par- a host of delinquent, legal and criminal problems.10–15 ticipate. Furthermore, studies may differ significantly as to their inclusion criteria and target populations. Those method- Estimation of adolescent gambling ological concerns contribute to results that vary significantly prevalence from country to country, or between different studies in the Turning to reported prevalence estimates on adolescent same country. gambling, we find a large variation depending on the country, measuring instrument, and target sub-population. The vast Favored forms of gambling among majority of relevant studies are population-based cross- adolescents and the impact of the sectional studies carried out with the aid of a diagnostic Internet questionnaire. There is a number of diagnostic, paper-pen Although adolescents do indulge in forms of gambling questionnaires validated throughout the world, including that are popular among adults (including games of cards the South Oaks Gambling Screen Revised for Adolescents like poker, sports wagering, dice, and board games, betting (SOGS-RA),16 Diagnostic and Statistical Manual-IV adapted on games of personal or peer skill, buying lottery tickets, format for Juveniles (DSM-IV-J),17 Lie/Bet Scale18 Canadian wagering or placing bets with a bookmaker), there has been Adolescent Gambling Inventory (CAGI),19 and the Gamblers a steady increase in adolescents turning to novel forms of Anonymous Twenty Questions (GA20),20 the most frequent gambling via the Internet.4,21,22 Typical factors that weigh of which are the SOGS-RA and DSM-IV-J. Those measures upon the choice of the particular gambling activity include are self-report instruments that have been directly adapted local availability and accessibility, gender (males may favor from adult versions. The benefit of a dual version of the same sports gambling more compared to female adolescents), age instrument is the ability to compare data between gamblers (older adolescents are more likely to engage in casino and in late adolescence and early adulthood in a population level, machine gambling, poker, and online gambling), cultural and also to monitor the trajectory of an individual gambler’s ethnicity, and socioeconomic status.9,23–25 Additionally, gambling behaviors from adolescence to adulthood, in clini- adolescents’ choice of gambling games differs from adults, cal practice. The drawback is that the questionnaires focus not only because gambling at this age is illegal, as it was on behaviors compatible with the established definition of always the case, but also because there is a technological gambling as a disorder implicitly involving money wagers, generation gap between the older generations and the current loss of money, or financial assistance by others in order to one; digital natives, as the younger generation is called due gamble. As we shall see later, this may not be always the case. to them being born in a world where digital communication and entertainment is the norm,26 are by definition exposed Worldwide prevalence rates of problem gambling to a new array of gambling opportunities. Those gambling A recent systematic review of published national studies up opportunities defy current classification attempts and cast to 2014 reported that problem gambling prevalence rates in a doubt as to the accurate estimation of the prevalence of North America ranged from 2.1% to 2.6% and in Oceania gambling as a whole. They include both commercial and from 0.2% to 4.4%, while in Europe, problem gambling simulated gambling, the difference of the latter being that prevalence rates ranged from 0.2% to 12.3%. Since then more there are no direct monetary gains and typically no fees data were published from all across the globe. A literature required to enter the gambling game. review of newer data from these past five years, since 2014, was carried out by running an NLM/PubMed, PsychINFO, Commercial and simulated gambling and Scopus query on the terms most frequently employed Gambling opportunities may or may not include gambling (gambling AND adolescent/youth/students/pupils/children/ with actual money and can thus be harder to study and 44 submit your manuscript | www.dovepress.com Adolescent Health, Medicine and Therapeutics 2018:9 Dovepress Dovepress Gambling disorder in adolescents: prevalence, developments, and challenges Table 1 Adolescent gambling studies with prevalence data since 2014 Author and date Sample Prevalence Wong and So 1,004 students in Hong 5.7% and 22.9% of the Internet gamblers could be classified